Grenfell Inquiry Report: Joining up the thinking and action

Sir Martin Moore-Bick describes the events of June 14, 2017 in forensic detail. They cannot be read without a quickening of the heart and a trepidation that is almost palpable. Knowing that 72 people lost their lives on that day and the bereaved, survivors and residents have to live with the memory of what happened makes this hugely significant and important report one that must not be relegated to the annals of history and forgotten over time.

The Grenfell Tower Inquiry Phase 1 Report is a salutary reminder to all fire and rescue services that competence, training and communication are core tenets of not only the response to incidents but are fundamental to risk planning in all parts of the business. Thinking of protection, prevention and response as separate activities within a fire and rescue service is no longer acceptable; fire and rescue is a complex blend of all three and the need to analyse the hazards and controls at all stages is critical to public safety.

The Grenfell Tower fire powerfully demonstrated that when controls fail and hazards are unimpeded, the consequences can be fatal. Planning is fundamental to the business of fire. Identifying risk and knowing how to respond is bread and butter to fire and rescue services. Not knowing that Grenfell Tower was wrapped in flammable cladding was not London Fire Brigade’s fault. Responding to the largest fire since the blitz was a massive challenge and one that will hopefully never happen again.

Of course, there is plenty to learn; of course, some things did not work as they should. The report contains 46 recommendations that are all about change and improvement, but whether they add up to cultural change remains to be seen and is dependent on whether the response is truly joined-up or simply a sequence of activity in silos.


“This demonstrates how complex fire safety is and each recommendation must not only be considered by London Fire Brigade but by government, every fire and rescue service and every residential building owner and manager across the UK”

London Fire Brigade Commissioner Dany Cotton


“Change cannot be achieved over night; this is a massive task that goes beyond changing policies and procedures. This is about cultural change on a massive scale. This is a sector wide issue.”

Fiona Twycross AM is the Deputy Mayor for fire in London. She talked about cultural change in her response to questions from the London Assembly after the publication of the Grenfell Tower Inquiry Phase 1 Report. At the meeting on November 5, London Fire Commissioner Dany Cotton and Assistant Commissioner Andy Bell were joined by NFCC Chair Roy Wilsher, NFCC Protection lead Mark Hardingham and FBU General Secretary Matt Wrack.

London Fire Brigade Response

The recording of this scrutiny session is well worth watching because it provides a rare insight into London Fire Brigade; since the tragic fire on June 14, 2017 LFB firmly closed its doors as the Inquiry carried out its work. This is not a criticism, it is natural that any organisation subject to such intense pressure from all quarters should seek to protect itself and its staff but this does not stop the curiosity or the interest in what it has to say.

When Fiona Twycross talked about the need for cultural change, she is right but the way to achieve it is by no means clear to see. With 46 recommendations contained in a report that runs to over 800 pages and weighs over four kg, there is a lot for London and indeed the wider Fire and Rescue Service to digest.

Dany Cotton told the London Assembly that London Fire Brigade would be responding to each of the recommendations. She cautioned: “Many of those recommendations are more complex than they first appear. This demonstrates how complex fire safety is and each recommendation must not only be considered by London Fire Brigade but by government, every fire and rescue service and every residential building owner and manager across the UK.”

During the November 5 meeting, Fiona Twycross asked London Assembly members how they wanted to track progress of the work to implement the recommendations. Whether this reporting would be simply London Fire Brigade actions or a wider response was unclear.

Fire and rescue services are by their very nature ‘can do’ organisations and the temptation is to just react; indeed there could be reactions from every fire and rescue service resulting in duplication of effort and inconsistent approaches. This is not the way it should be done. There is time to put in place a joined-up consideration of the recommendations that is more thoughtful and needs to be done in context. Cultural change is not found in single organisations responding to 46 recommendations; cultural change takes time, takes account of myriad influences and embraces the wider organisations along the way.

It will be hard to withstand the pressure to react, as is made clear by the government’s response. The Prime Minister said in parliament on the day of the report’s publication: “We plan to accept in principle all the recommendations that Sir Martin makes for central government. We will set out how we plan to do so as quickly as possible, but I can assure the House and all those affected by the Grenfell tragedy that where action is called for action will follow.”


“We need something fundamentally different if we are going to actually seriously change the culture in relation to fire and rescue services and Fire and Rescue Service policy in the UK”

FBU General Secretary Matt Wrack


Call for Joined-up Approach

Matt Wrack is consistent in his view that a joined-up approach to dealing with the consequences of the Grenfell Tower Fire is the only way forward. He is, as ever, skeptical of a Conservative government and the fire ‘establishment’. “If we are going to hand this back to the same people who have been there, overseeing this for years, I have to say I don’t find that convincing. We need something fundamentally different if we are going to actually seriously change the culture in relation to fire and rescue services and Fire and Rescue Service policy in the UK.”

Since then, the FBU has written to UK governments, London Fire Brigade, the NFCC, LGA and others seeking an urgent meeting to discuss the recommendations from the Inquiry with a view to seeing them implemented ‘quickly and efficiently’.

A national approach makes sense as many of the recommendations are not just about London but resonate more widely. Getting all the bodies that the FBU would like to see around a table will be a challenge as no doubt they are already in their respective silos, beavering away at finding their own ways through this.

The report covers a wide range of Fire and Rescue Service business, from planning and preparation right across command and control. ‘Stay put’ and evacuation has been the subject of considerable (and understandable) public interest. London Fire Brigade alongside the NFCC have called on the government to commission national research into how to transition from ‘stay put’ to ‘get out’ and understand the complexity that the subsequent evacuation (or rescue) entails.

There has been less interest in the subject of joint working. Towards the end of the recommendations, Sir Martin looks at the Joint Doctrine and how interoperability works at a major incident.

Joint Doctrine and Interoperability

The Grenfell Tower Fire came shortly after the May 22, 2017 Manchester terrorist attack. Lord Kerslake published his report into the emergency services response to the attack in March 2018. There are over 70 recommendations and reading them now, in the light of the Grenfell report, there are similarities in the area of joint working that should not be neglected.

Sir Martin Moore-Bick has much to say about joint working and the multi-agency response on June 14, 2017, as does Lord Kerslake. There are 15 recommendations focused on fire and rescue in the Kerslake report, and, like the Grenfell report, they go beyond the geographical boundaries of the responding fire and rescue service: competence, communication and training feature heavily in both reports.

There are different views in the two reports about the Joint Doctrine (the Interoperability Framework) published by JESIP. Lord Kerslake writes, in his final recommendation for fire and rescue: ‘The response to the Arena attack provided an extraordinary validation of the on-going work within the UK civil protection sector to embed the JESIP Interoperability Framework in practice’. He praises responders where the principles of JESIP held good, but goes on to say: ‘Where unforeseen limitations in guidance, protocol and circumstance collided to block such collaboration, the response of the organisation affected was paralysed for a crucial period’.


“Change cannot be achieved over night; this is a massive task that goes beyond changing policies and procedures. This is about cultural change on a massive scale. This is a sector wide issue”

Fiona Twycross AM, London


In contrast, Sir Martin is less sympathetic when it comes to the Joint Doctrine. ‘The Joint Doctrine is well-intentioned, but it is not an easy document to navigate or penetrate beyond the first few pages’. He goes on: ‘I hope it is not unfair to say that it bears all the hallmarks of managerial conceptualism, designed to fulfill a statutory requirement in a vacuum, and does not appear to be based on the experience of those who operate on the incident ground in the real world’.

He says that the Category 1 responders (LFB, MPS, LAS and the London Borough of Kensington and Chelsea) did not fully adhere to the principles contained in the Joint Doctrine with the principle, common to all, being poor communication. The consequence of this was organisations working in isolation and in ignorance of what others were doing.

Both reports make a similar recommendation about METHANE messages. This acronym represents the common model for passing incident information between services and their control rooms. This is clearly an issue, but how will this be addressed across the UK?

A ‘METHANE’ message should be sent as soon as possible by the emergency service declaring a Major Incident. (Grenfell Tower Inquiry Phase 1 Report, chapter 33.31)

[GM Resilience Forum members] should develop contingencies to enable METHANE messages to be shared directly between partner agencies’ control rooms immediately upon receipt of a message from the incident scene. (Kerslake Report, p182)

Ensuring that recommendations from the Kerslake Report and from the Grenfell Tower Inquiry Phase 1 Report are addressed and the actions arising monitored and shared in a transparent way are critical for retaining public confidence in the process. It is incumbent on those who are responsible for providing services to the public to work together not only for efficiency but for the quality of the outcome. The METHANE example above demonstrates how one issue can appear in two reports published more than 18 months apart and be addressed twice or not at all. The question is how will the public know?

All of which returns to the point made by the FBU that there should be a joined-up approach to responding to the recommendations from the Grenfell Tower Inquiry and that work must be done in the context of other learning; reports such as Kerslake and what has emerged from inspection findings as well as reports into major fires from years gone by. London Fire Brigade came in the third and final tranche of inspection and scrutiny of their inspection report will provide useful context for the response the Grenfell recommendations.

National Resourcing

Who will pick up the tab for all this work? Roy Wilsher, Chair of the NFCC, said at the London Assembly meeting: “The other recommendation I would have like to have seen was some sort of resource implications, support from government to help fire and rescue services nationally to look at these recommendations and turn them into policy for us.” Matt Wrack agreed with this point noting: “It cannot be done on the cheap.”

Fiona Twycross told London Assembly members that she will go to the Mayor’s budget committee but said that she would be looking for a national solution that has national funding. On the face of it, all three major players here seem to be on the same page: they want national approaches, national solutions and national money, but what are the practicalities of making this happen?

Remember too that the NFCC has the Inspectorate on its side and should take advantage of the recommendation they make in their tranche two report. HMICFRS said: ‘As part of the next Spending Review, the Home Office in consultation with the Fire and Rescue Sector should address the deficit in the fire sector’s national capacity and capability to support change’. The preamble suggests that this means providing the NFCC with more money but it could be interpreted to be more widely applied.

There would be strength in a joined-up approach to government to access extra funding. Fire and rescue policy sits with the Home Office, but with much of the attention on Grenfell sitting with the Building Safety Programme located in the Ministry for Housing and Local Government, getting both government departments to align and agree will make the task much harder. But it is doable, particularly if there is a majority government (not known at the time of writing).

Sir Martin Moore-Bick and his team have done an incredible job, sifting through and analysing hundreds of thousands of documents to make sense of what happened on June 14, 2017. It is now time for those in positions of power and influence to ensure that the right change happens at the right time. The only way to do this is to work together. All the key players need to be open and transparent and resist the temptation to retreat. They need to put the interests of the public first because after all, public safety is what this is all about and that should not be forgotten.

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